Recent studies indicate that cancer-associated fibroblasts (CAFs) are phenotypically and functionally heterogeneous. However, little is known about CAF subtypes, the roles they play in cancer progression, and molecular mediators of the CAF “state.” Here, we identify a novel cell surface pan-CAF marker, CD49e, and demonstrate that two distinct CAF states, distinguished by expression of fibroblast activation protein (FAP), coexist within the CD49e+ CAF compartment in high-grade serous ovarian cancers. We show for the first time that CAF state influences patient outcomes and that this is mediated by the ability of FAP-high, but not FAP-low, CAFs to aggressively promote proliferation, invasion and therapy resistance of cancer cells. Overexpression of the FAP-low–specific transcription factor TCF21 in FAP-high CAFs decreases their ability to promote invasion, chemoresistance, and in vivo tumor growth, indicating that it acts as a master regulator of the CAF state. Understanding CAF states in more detail could lead to better patient stratification and novel therapeutic strategies.

Objective The aim of the study was to determine how experts treat vulvar high-grade squamous intraepithelial neoplasia (VHSIL) and differentiated vulvar intraepithelial neoplasia (dVIN). Method A 26-question survey was designed through a literature review, reviewed by the Survey Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), and distributed to all ISSVD members via e-mail in January 2019. Results Overall, 90 of 441 physician members consented to participate and 78 of 90 were eligible to complete the survey. Most respondents were gynecologists (77%), followed by dermatologists (12%). Forty-five percent responded that their pathology was being reported using the 2015 ISSVD terminology of vulvar squamous intraepithelial lesions. The most common first-line treatments were as follows: unifocal VHSIL—excision (65%), multifocal VHSIL—imiquimod 5% (45%), VHSIL in a hair-bearing area—excision (69%), and clitoral disease—imiquimod 5% (47%). In the recurrent VHSIL, excision was favored (28%), followed by imiquimod 5% (26%) and laser (19%). Differentiated vulvar intraepithelial neoplasia was most often first treated with excision (82%), and more patients were referred to gynecologic oncology. Most patients were seen in follow-up at 3 months (range: 1 week–6 months). Sixty-seven respondents provided 26 different ways to follow treated patients, which were most commonly every 6 months for 2 years and then yearly (25%), followed by every 6 months indefinitely (18%). Conclusions Treatment of VHSIL and dVIN varies among vulvar experts with excision being the most common treatment, except in multifocal VHSIL where imiquimod is commonly used. There is wide variation in how patients are followed after treatment.

Objective The aim of the study was to evaluate the effectiveness of “The Vulva Diaries” podcast as a novel learning tool for vulvovaginal disease education. Materials and Methods Medical students and residents were invited to participate in the study using social media advertisements. Online pretests and posttests, one based on a podcast episode regarding genital herpes and the other on lichen sclerosus, were used to assess changes in knowledge level pre– and post–podcast listening in medical students and residents respectively. A second posttest was sent out 2 weeks after the first to assess knowledge retention. Results were analyzed using paired t tests comparing mean scores before and after podcast. Results In medical students, the average test score increased by 20% (n = 56, p < .001). Similarly, in residents the average test score increased by 23.1% (n = 22, p < .001). Medical students and residents rated their average preference for using podcasts as compared with other resources at 3.6 and 3.7/5, respectively. Furthermore, in both groups, there was no significant difference between average scores for posttest 1 versus posttest 2 written 2 weeks later suggested excellent knowledge retention. Conclusions “The Vulva Diaries” podcast increases knowledge on vulvovaginal disease and is an effective learning tool for health care trainees in women's health. This study emphasizes the role of podcasts as a valuable educational resource within gynecology. The success of such initiatives will hopefully bolster the effort to correct the lack of provider knowledge in treating vulvovaginal diseases.

High grade serous ovarian cancer (HGSOC) is the most common and lethal subtype of ovarian cancer. Many cancers, including HGSOC, contain a “stromal” component comprised of cancer-associated fibroblasts (CAFs), immune cells, and blood vessels, as well as their secreted factors and extracellular matrix. This complex microenvironment plays a significant role in promoting tumor growth, therapy resistance, and invasion. The majority of studies of CAFs utilize cells cultured and passaged in vitro under crude conditions to maintain their viability. Such conditions alter the original phenotype of the cells and may select for specific subpopulations to grow out. To facilitate direct isolation of CAFs from primary tumor tissues, we screened a panel of antibodies to identify cell surface proteins that are uniquely expressed on CAFs. We discovered CD49e as a mesenchymal marker and then validated its specificity to CAFs through immunohistochemistry on tissue sections obtained from HGSOC patients. The discovery of CD49e as a CAF-specific cell surface marker facilitated fluorescence-activated cells sorting (FACS) to isolate CAFs directly from primary tumors, allowing us to avoid in vitro manipulation and to characterize their transcriptional and functional profiles in the primary setting. We next performed transcriptional profiling of primary CAFs isolated from 12 HGSOC patients and found that CAFs fall into two subgroups with unique gene expression signatures. A cell surface protein, fibroblast activation protein (FAP) is the defining marker for separating the two subgroups (FAP-Hi and FAP-Lo). The FAP-Hi subgroup possesses the classical gene signature of CAFs that is reported in the literature. When we isolated FAP-Hi and FAP-Lo cells and placed them into classical CAF growth conditions in vitro, both cell types had mesenchymal features, but FAP-Hi cells grow faster. Thus under the classical conditions for growing CAFs, FAP-Hi cells have a growth advantage, outcompeting FAP-Lo cells and becoming the dominant cells used for experimentation. Flow cytometry for FAP indicates that both CAF subtypes co-exist in every tumor, but their ratio varies from one patient to another. Patients whose tumors are dominated by FAP-Hi CAFs have worse clinical outcome than patients whose tumors are dominated by FAP-Lo CAFs. Thus, we have functionally characterized the role of FAP-Hi and FAP-Lo fibroblasts in the context of HGSOC. We have shown that FAP-Hi fibroblasts support tumor proliferation and invasion of ovarian cancer cells in vitro and in vivo. On the other hand, FAP-Lo cells suppress cancer cell proliferation and invasion in vitro and in vivo. Citation Format: Ali Hussain, Veronique Voisin, Stephanie Poon, Jalna Meens, Julia Dmytryshyn, Gary Bader, Benjamin Neel, Laurie Ailles. A novel signature of mesenchymal stromal cells in high-grade serous ovarian carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 140.